103 STAT. 2178 PUBLIC LAW 101-239—DEC. 19, 1989 graph (4)), and the gec^aphic physician work acb'ustment factor (specified in paragraph (5)) for the service and the area. "(3) GEOGRAPHIC CO6T-OP-PRACTICE ADJUSTMENT FACJTOR.— For purposes of paragraph (2), the 'geographic cost-of-practice adjustment factor', for a service for a fee schedule area, is the product of— "(A) the proportion of the total relative value for the service that reflects the relative value units for the practice expense component, and '(B) the gec^aphic cost-of-practice index value for the area for the service, based on the index established under paragraph dXAXi) or (I)(B) (as the case may be). "(4) GEOGRAPHIC BSALPRACTICE ADJUSTMENT FACTOR.— For pur- poses of paragraph (2), the 'geographic malpractice a4justment factor', for a service for a fee schedule area, is the product of— "(A) the proportion of the total relative value for the service that reflects the relative value units for the mal- practice component, and "(B) the geographic malpractice index value for the area, based on the index established under paragraph (IXAXii). "(5) GEOGRAPHIC PHYSICIAN WORK ADJUSTMENT FACTOR.—For purposes of paragraph (2), the 'geographic physician work adjustment factor', for a service for a fee schedule area, is the product of— "(A) the proportion of the total relative value for the service that reflects the relative value units for the work component, and "(B) the geographic physician work index value for the area, based on the index established under paragraph (IXAXiii). "(f) MEDICARE VOLUME PERFORMANCE STANDARD RATES OF IN- CREASE.- "(1) PROCESS FOR ESTABLISHING MEDICARE VOLUME PERFORM- ANCE STANDARD RATES OF INCREASE.— "(A) SECRETARY'S RECOMMENDATION.— By not later than April 15 of each year (beanning with 1990), the Secretary ^ shall transmit to the Congress a recommendation on performance standard rates of increase for all physicians' services and for each category of such services for the fiscal year banning in such year. In making the recommenda- tion, t^e Secretary shall confer with organizations rep- resenting physicians and shall consider— "(Dmflation, "(ii) changes in numbers of enrollees (otiier than . HMO enrollees) under this part, "(iii) changes in the age composition of enrollees (other than IDIO enrollees) under this part, "(iv) changes in technology, "(v) evidence of inappropriate utilization of services, "(vi) evidence of lack of access to necessary physi- cians' services, and "(vii) such other factors as the Secretary considers appropriate. "(B) (COMMISSION REVIEW.— The Physician Payment Review Commission shall review the recommendation transmitted during a year under subpars^aph (A) and shall make its recommendation to Congress, by not later
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